Vehicle Repair Refusal Waiver Form
Complete this form to acknowledge refusal of recommended vehicle repairs after inspection or diagnosis. Please review all information carefully before submitting.
Full Name of Vehicle Owner or Authorized Person
*
First Name
Last Name
Contact Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Vehicle Identification Number (VIN) or License Plate
*
Vehicle Make
*
Vehicle Model
*
Vehicle Year
*
Date of Repair Refusal
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Description of Repairs Being Declined
*
Reason for Refusal (optional)
Waiver and Acknowledgment:
I acknowledge that I have been advised of the recommended repairs for the above vehicle following inspection or diagnosis. I understand that by refusing these repairs, the vehicle may remain unsafe or in need of repair, which could result in further damage, unsafe operation, or potential injury. I accept full responsibility for any consequences resulting from my decision to decline the recommended repairs.
Signature of Vehicle Owner or Authorized Person
*
Submit Waiver
Submit Waiver
Should be Empty: